Alzheimer Disease Infusion Service Appointment

Attach your referral here (pdf preferred)

Your Name (required)

Date of Birth (required)

Your Address (required)

Your Email (required)

Phone number (mobile preferred)

I have been diagnosed with (select type a diagnosis)

—Please choose an option—Mild Cognitive Impairment (MCI)Mild Azlehimer DiseaseAlzheimer DiseaseUnsure

The name of your referring Specialist

This doctor is (select type of specialist)

—Please choose an option—NeurologistGeriatricianPsychiatristUnsure

I am aware that there are strict eligibility criteria for treatment with Donanemab (Kisunla) and Lecanemab (Leqembi)(select an answer)

—Please choose an option—YesNo

I am aware that the costs for treatment with Donanemab (Kisunla) and Lecanemab (Leqembi) are likley to exceed $90,000 (select an answer)

—Please choose an option—YesNo

Preferred location for appointment(required)

—Please choose an option—St Kilda RoadBox Hill

Preferred time for appointment (required)

Please leave this field empty.